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AN ' ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS M -51 CG. eA RFF M�K- CITY/ZIP 5r0 GkTPA[ '95-7-1f- CROSS 95-7-1fCROSS STREET /!2?g[t/PD S A lL D - APN r 7 9- /GD— D PARCEL SIZE 3,9.3 3 Y v OWNER NAME VA-Et 'f' 0NAKMARA AArN PHONE 261n:479 6-267A OWNER ADDRESS a39 3 Z E CrA'QF h(75�F— CITY/STATE21P STo 0KT2it/ 9 T2t 5 CONTRACTOR C-44 C--5 til E �u i-ne61l. PHONE :;?O f -4-P 7-—/&' a Q CONTRACTOR ADDRESS V O�jX 3/7 / CITY/STATE/ZIP C� /IZLO � CA ��3U2 LICENSE I II iC-42 L I i IC-36 OTHER ILC G NUMBER EXPIRATION DATE W TER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: Ll RESIDENCE I I COMMERCIAL I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES I I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH It LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE To NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS CO NSATION LAWS. MI M 48 HQR ADVANCE NOTICE REQUIRED FOR INSPECTIOrNS,-PLEASE CALL 209 953-7697 SIGNED TITLE LSI�/L �/�G/NEEJe DATE a ENT— A J A UI C U c a t cn n p D PARTMEN US ONLY6A iA, /� Application Accepted B ate / t Are 'L Employee ID# Final Inspection By Date I_I SPECIAL PERMIT-Approved by Character of Soil to Dep(h of t: PIU mp Soil C aracter: COMMENTS * 1 -� -r21- a a � - q- + ``LC c I rra -t' 1 3,. l .e •es . PE SC Received Amount DatePermit/ Invoice# Permit ID# ' Code INFO B Cash Remitted Ser ce Re ues # 22 Sz3 35- o I i� 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17